Association between hypertensive urgencies and subsequent cardiovascular events in patients with hypertension.

OBJECTIVE: To determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event. METHODS: Overall, 384 patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/or a diastolic blood pressure above 120 mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85-110 mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years (interquartile range 2.9-5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up. RESULTS: Overall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies (88 vs. 42; P = 0.005). The Cox regression analysis identified age (P < 0.001) and hypertensive urgencies (P = 0.035) as independent predictors for subsequent cardiovascular events. CONCLUSIONS: Hypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.

Can brain natriuretic peptide predict outcome after cardiac arrest? An observational study.

BACKGROUND: No accurate, independent biomarker has been identified that could reliably predict neurological outcome early after cardiac arrest. We speculated that brain natriuretic peptide (BNP) measured at hospital admission may predict patient outcome. METHODS: BNP-levels were measured in 155 comatose cardiac arrest survivors (108 male, 58 years [IQR 49-68]) (median time to ROSC 11min; IQR 20-30) during a 6-year study period. Cardiovascular co-morbidities and resuscitation history were assessed according to the Utstein-style and patients were followed for 6-month neurological outcome measured by cerebral performance category (CPC) and survival. RESULTS: Seventy patients (45%) suffered from unfavourable neurological outcome and 79 deaths (51%) occurred during the first 6 months. BNP was significantly associated with an adverse neurological outcome and mortality, independent of the prearrest health condition and cardiac arrest characteristics (median 60 pg/ml; IQR 10-230). Adjusted odds ratios for poor neurological outcome at 6 months were 1.14 (95% CI 0.51-2.53), 1.76 (95% CI 0.80-3.88) and 2.25 (95% CI 1.05-4.81), for increasing quartiles of BNP as compared to the lowest quartile. Adjusted odds ratios for mortality until 6 months were 1.09 (95% CI 0.35-3.40), 2.81 (0.80-9.90) and 4.7 (1.27-17.35) compared to the lowest quartile, respectively. CONCLUSION: Brain natriuretic peptide levels on admission predict neurological outcome at 6 months and survival after cardiac arrest.

Platelet function predicts myocardial damage in patients with acute myocardial infarction.

BACKGROUND: Platelet activation is a hallmark of acute coronary syndromes. Numerous lines of evidence suggest a mechanistic link between von Willebrand factor or platelet hyperfunction and myocardial damage in patients with acute coronary syndromes. Thus, we assessed whether platelet function under high shear rates (collagen adenosine diphosphate closure times [CADP-CTs]) measured with the platelet function analyzer (PFA-100) may be enhanced in patients with myocardial infarction (MI) and whether it may predict the extent of myocardial damage as measured by creatine kinase (CK-MB) or troponin T (TnT) levels. METHODS AND RESULTS: Patients with acute chest pain or symptoms suggestive of acute coronary syndromes (n=216) were prospectively examined at an emergency department. CADP-CT was significantly shorter in patients with MI, particularly in those with an ST-segment-elevation MI (STEMI) compared with the other patient groups (unstable angina, stable coronary artery disease, or controls). Furthermore, CADP-CT and collagen epinephrine-CT at presentation were independent predictors of myocardial damage as measured by CK-MB or TnT. Patients with MI whose CADP-CT values fell in the first quartile had 3-fold higher CK-MB and TnT levels than those in the fourth quartile. CONCLUSIONS: Patients with STEMI have significantly enhanced platelet function when measured under high shear rates. CADP-CT is an independent predictor of the severity of MI, as measured by markers of cardiac necrosis. Measurement of platelet function with the PFA-100 may help in the risk stratification of patients presenting with MI.

Association between course of blood pressure within the first 24 hours and functional recovery after acute ischemic stroke.

STUDY OBJECTIVE: The relation between course of blood pressure within the first 24 hours after acute stroke and early neurologic outcome remains a matter of dispute. We investigate this relation with adjustment for other influencing variables. METHODS: Three hundred seventy-two patients with the diagnosis of ischemic stroke were included to evaluate the relation between blood pressure course and early neurologic outcome. The following data were collected: age; sex; history of hypertension, diabetes mellitus, hyperlipidemia, coronary heart disease, peripheral vascular disease, and stroke; smoking habits; preadmission blood pressure, blood pressure on admission, and blood pressure 24 hours later; antihypertensive treatment; and stroke localization. We assessed outcome at day 5 after admission as dependent or independent (Rankin Scale score

Is fasting blood glucose a reliable parameter for screening for diabetes in hypertension?

BACKGROUND: The aim of this study was to evaluate the sensitivity and specificity of a combination of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA(1c)) for screening for diabetes in hypertensive patients. The oral glucose tolerance test (OGTT) served as a gold standard for the detection of diabetes. METHODS: The cross-sectional study was performed in the Hypertension Unit of the Department of Emergency Medicine in the General Hospital of Vienna between January 1999 and July 2001. The FPG, HbA(1c), and OGTT were performed in 152 hypertensive patients (77 male and 75 female) to identify those individuals with diabetes. RESULTS: A total of 33 patients were identified as diabetic based on the results of the OGTT. Diabetes was detected in 25 (16%) of 152 patients using an FPG > or =7.0 mmol/L. In addition, HbA(1c) was measured in the remaining 127 (84%) patients with an FPG <7.0 mmol/L. In these patients HbA(1c) > or =6.1% showed a sensitivity of 100% and a specificity of 75%. Cost analysis of both approaches (FPG + HbA(1c) versus OGTT in all patients) demonstrated a cost sparing effect of 31.03 $/patient (31.66$/patient) in favor of the combined use of FPG and HbA(1c). CONCLUSION: The combination of FPG and HbA(1c) is a reasonable alternative to the generally recommended OGTT for the screening of diabetes, as diabetes was correctly diagnosed in all patients by this stepwise procedure.

Factors influencing the accuracy of oscillometric blood pressure measurement in critically ill patients.

OBJECTIVE: Comparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department in a 2000-bed inner-city hospital. PATIENTS: A total of 30 patients categorized into three groups according to their upper arm circumference (I, 18-25 cm; II, 25.1-33 cm; III, 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS In each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery. MEASUREMENT AND MAIN RESULTS: Overall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was -2.4 +/- 11.8 mm Hg (p <.0001) and, with the M1008A, -5.3 +/- 11.6 mm Hg (p <.0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 +/- 13.4 mm Hg (p <.024) and, with the M1008A, -2.3 +/- 11.5 mm Hg (p <.0001). CONCLUSION: The new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.

Classification of blood pressure levels by ambulatory blood pressure in hypertension.

Whereas clinic blood pressure (CBP) above normality is divided into stages, no corresponding classifications are available for 24-hour ambulatory blood pressure (ABP). We conducted a study (1) to define stages of hypertension by ABP corresponding to CBP stages and (2) to evaluate if these stages have prognostic impact similar to CBP stages. Seven hundred thirty-six hypertensive patients were included. Mean systolic blood pressure was 149+/-15.2/87+/-8.6 mm Hg for CBP and 135+/-13/79+/-9.7 mm Hg for ABP. The mean bias between both methods was -13.3 mm Hg (95% CI, -14.3 to -12.2; 1.96xSD limits of agreement, 15.7 to -42.3) and -7.3 mm Hg (95% CI, -7.9 to -6.6; 1.96xSD limits of agreement, 9.8 to -24.3) for systolic and diastolic blood pressure (P>0.0001 for both), respectively. Classification of hypertension by ABP revealed lower cutoff values for the different stages of hypertension compared with the corresponding cutoff values for CBP (CBP versus ABP: 140/90 versus 132/81 mm Hg; 160/100 versus 140/88 mm Hg; 180/110 versus 148/94 mm Hg, P<0.001). Overall, 82 (11.1%) patients had nonfatal clinical cardiovascular events and 9 (1.2%) patients died of a cardiovascular cause during follow-up. The distribution of cardiovascular events was significantly associated with increasing ABP value (P<0.006). Staging of hypertension by ABP may facilitate the use of this method in daily clinical practice, as ABP can now be used not only to confirm the diagnosis of hypertension but also to assess the severity and prognosis of hypertensive disease.